The Burn Patient

E . James Radin , MD

Objectives

ABA guidelines for transport to burn center Signs of inhalation Assessment of surface involved Burn formulas Evaluation and management

Describe the types of burns Population at risk

Epidemiology
30 , 000 admissions a year all age groups at risk Mortality increases with age Males predominate 2 million burns per year

Inhalation , Thermal , Chemical , Electrical Scenes are not always safe for providers

Estimates of Involved Surface

Rule of Nines . . . . . . . . .

Degree of Burn

First Degree

Second Degree

Third Degree

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Facial Burns
Surface Ocular Airway

Rapidly progressive deterioration

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Singed Nasal Hairs Airway edema Glossal Swelling Epiglottic edema Glottic edema

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Ocular Burns

Contact lenses need to be removed Copious irrigation Sterile dressings Notify ED ASAP to arrange
Opthamology Evaluation

Often chemical

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Pulmonary Burns
Closed space

Rapidly progressive deterioration

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Carbonaceous sputum Singed nasal hairs Lip edema Thermal Chemical Foreign debris

Facial involvement

Pulmonary Burns
ABCs

Definitive control of the airway Humidified Oxygen Prevent Hypoxia Assist Ventilation NG / Oral Gastric tubes

Do Not Delay Transport to a Burn

Center for Diagnostic Tests
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Circumferencial Burns
Fluid replacement causes edema

Compartment pressures can go above arteriolar Monitor . . . . . . . . Pulses

Capillary leaks / tighten the extremity

Tightness / Compartment pressures

Doppler flow

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Electrical Burns
CNS injury

Renal injury / direct electrical / myoglobin Entry and Exit wounds AC / DC

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Low / high voltage < 1000 volts > Muscle injury / Myoglobinemia

Low / high resistance tissues

Peripheral nerve injury Cardiac arrhythmias Occult injury

Electrical Burns
Arrhythmia when they occur usually at time of

injury , not delayed Bone and skin are high resistance , occult injury very common Look for entry and exit wounds , all tissue between is at extreme surgical risk Myoglobinemia from muscle injury can shut down kidneys AC is more dangerous than DC Duration of shock determines extent of injury
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Burns can be by direct contact or by arcing

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Chemical Burns
Treatment Specific . . . . . . . . Hydrofluoric : Irrigate , Calcium Gluconate HCL / Sulfuric : Bicarbonate irrigation Phenol : No irrigation White Phosphorous : Ignites with irrigation Sample or container to hospital ! ! ! Treatment Kits at Industrial Sites ! ! !
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Fluid Resuscitation

burn Aggressive fluids are not needed for short trip Do not waste scene time for IV if under 15 minutes to the burn center

> 15 % , Edema even where there is no

Rapid volume depletion Diffuse capillary leaks

Fluids critical for the long flight ! ! !

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Fluid Resuscitation
Large bore IV (s)

1 . 0 cc / kg / hr child [ < 30 kg ] Too much fluids can be just as bad as too little ! ! !

Best tool , Urine Output . . . . 0 . 5 cc / kg / hr adult

Non - burn site if possible

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Parkland Formula

% BSA x Kg x 4 cc = 24 hour total

need

1 / 2 over the next sixteen hours Lactate Ringers is the fluid of choice !
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1 / 2 over the first eight hours

Modified Brooke Formula

% BSA x Kg x 2 cc = 24 hour total

need

1 / 2 over the first eight hours 1 / 2 over the next sixteen hours
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Wound Care

Compensate for loss of thermoregulation Provide comfort and pain control Dry linen dressings , not gauze Do not cool wound , can advance the Regulate ambient temperature
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Do not remove adherent clothing

After the initial resuscitation Remove smoldering clothing

degree of burn

Burn Center Transport Guidelines

Involvement of hands , perineum , face ,

feet Inhalation All high voltage All chemical Patients with significant pre - existing disease

Partial thickness over 15 % Full thickness over 5 %

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